Form Wv/mft-509 Gas - Motor Fuel Excise Tax Refund Application For Sales To Federal Government - 2007

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DEPARTMENT USE ONLY
Postmark Date:
WV/MFT-509 GAS
WEST VIRGINIA STATE TAX DEPARTMENT
ORG 12/07
INTERNAL AUDITING DIVISION
PO BOX 2991
CHARLESTON, WV 25330-2991
THIS FORM IS TO BE USED FOR
OVERPAYMENTS, ERRONEOUS
MOTOR FUEL EXCISE TAX
PAYMENTS AND/OR FOR SALES
OF MOTOR FUEL TO A UNITED
REFUND APPLICATION FOR SALES TO
STATES GOVERNMENT ENTITY
WHO HAS REFUSED TO PAY THE
FEDERAL GOVERNMENT WHO REFUSE
MOTOR FUEL EXCISE TAX
PAYMENT OF TAX OR
OVERPAYMENT/ERRONEOUS PAYMENTS
GASOLINE
PLEASE PRINT OR TYPE
WV Identification Number:
Contact Person:
Name:
Telephone:
Ext:
DBA:
Address:
City:
State:
Zip:
United States Government entity that did not pay the taxes; give full details and attach invoices that shows the amount billed and the amount that was paid by the
US Govt. entity. Overpayment and erroneous payments; submit full details and supporting documents.
FUEL ACCOUNTABILITY - PLEASE READ INSTRUCTIONS ON BACK CAREFULLY
GALLONS
OFFICE USE
Incomplete forms will be returned and will cause a delay in your refund.
A. Total Gallons Billed
B. Total Dollar amount of Invoice(s) including the Motor Fuel Tax
$
C. Total Amount paid
$
D. Total Amount of Motor Fuel Tax not paid
(
$
Line B minus Line C)
E. Gallons to be considered for Refund
(Line D divided by tax rate)
Flat rate currently $0.2050 per gallon; Variable rate currently $0.117 per gallon
F.
GALLONS CLAIMED FOR REFUND
(same as Line E)
$
$
G.
TOTAL REFUND DUE
(Line F x $0.322)
.
CAUTION: Please read this application before signing. Presenting a fraudulent application constitutes a felony
I certify that, to the best of my knowledge, this application is accurate and complete.
SIGNATURE: _______________________________________ TITLE: ___________________________________
DATE: __________________
DEPARTMENT USE ONLY
GOVERNMENT
AMOUNT OF REFUND $____________________
Affidavit on page two must be notarized and signed.
APPROVED BY: __________________________
DATE: ___________________________________
SERIAL NUMBER:

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